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Childcare Reimbursement Application

To apply for childcare reimbursement through UW-Washington County's Student Government Association (SGA), you will need to:

Enroll for a minimum of six credits at UW-Washington County.

Complete this form. Note: Application period is limited to the first ten weeks of the fall and spring semesters.

Submit a copy of your class schedule. (Drop off a copy of your schedule in the main office to the attention of Debbie Butschlick or email a copy to debbie.butschlick@uwc.edu.)

Wait approximately seven business days for decision. When all information is received, you will be contacted regarding the committee's decision on your individual case. The rate of reimbursement is based on the number of accepted applicants and the amount of class hours per week each applicant has. The reimbursement amount will not exceed $2.00 per contact hour.

If you have questions with this form or need additional help, contact Debbie Butschlick.

First Name *

M. I.

Last Name *

Email *

Address

City

State

Zip

Credits Registered for in the current semester *

Number of children for which you will claim *

Ages of children for which you will claim

Do you receive any other Federal or State money for school tuition or child care? *

Yes

No

Indicate the name of the program(s) *

Childcare Provider Information

Name of Provider *

Director (if a facility)

Address

City

State

Zip

Phone

Amount paid per week $

Please provide a brief description of your daily routine to allow us to get a better idea of your need for this service.

Note: Please press submit only once. Allow a minute or so for information to transfer. To receive any funding, a copy of your CURRENT CLASS SCHEDULE must be submitted. Email a copy to Deb Butschlick or drop off a copy in the main office (to her attention) or in her office (located in far corner - within gymnasium).